N.H. Code Admin. R. Saf-C 311.23 - Form RT 115, Road Toll Refund Application for Retail Dealer

(a) An applicant shall submit the following on form RT 115:

(1) Distributor's:

a. Name and address;

b. Telephone number; and

c. Federal employer identification number, if applicable;

(2) Retail dealer's:

a. Name and address;

b. Telephone number; and

c. Federal employer identification number, if applicable;

(3) Period covered;

(4) Mailing address for refund;

(5) Gross gallons purchased, by product type;

(6) Road toll rate;

(7) Amount paid;

(8) Refund rate;

(9) Amount of refund request;

(10) Total gasoline; and

(11) Total toll paid on diesel gallons.

(b) The retail dealer shall sign the form.

(c) The licensed distributor shall sign the form.

Notes

N.H. Code Admin. R. Saf-C 311.23

(See Revision Notes #1 and #2 at chapter heading for Saf-C 300) #10032, eff 11-22-11

Renumbered From Saf-C 311.21 Volume XXXV Number 1, Filed January 8, 2015, Proposed by #10753, Effective 1/1/2015.